Table Of ContentS. Hrg. 106-519
HEALTH CARE FOR THE UNINSURED: THE ROLE
OF SAFETY NET PROVIDERS
HEARING
BEFORE THE
SUBCOMMITTEE OX PUBLIC HEALTH
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED SIXTH CONGRESS
SECOND SESSION
ON
EXAMINING TftE ACCESS OF ESSENTIAL HEALTH CARE SERVICES FOR
THE UNINSURED AND MEDICALLY UNDERSERVED INDIVIDUALS, FO-
CUSING ON CERTAIN SAFETY NET PROGRAMS TO REDUCE THE BAR-
RIERS AND INCREASE HEALTH INSURANCE ACCESS TO THE UNIN-
SURED, AND THE PROPOSED COMMUNITY ACCESS TO HEALTH CARE
ACT
MARCH 23, 2000
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
JAMES M. JEFFORDS, Vermont, Chairman
JUDD GREGG, New Hampshire EDWARD M. KENNEDY, Massachusetts
BILL FRIST, Tennessee CHRISTOPHER J. DODD, Connecti«ut
MIKE DeWINE, Ohio TOM HARKIN, Iowa
MICHAEL B. ENZI, Wyoming BARBARA A. MIKULSKI, Maryland
TIM HUTCHINSON, Arkansas JEPT BINGAMAN, New Mexico
SUSAN M. COLLINS, Maine PAUL D. WELLSTONE, Minnesota
SAM BROWNBACK, Kansas PATTY MURRAY, Washington
CHUCK HAGEL, Nebraska JACK REED. Rhode Island
JEFF SESSIONS. Alabama
Mark E. Powden, StaffDirector
Susan K. Hattan, Deputy StaffDirector
Michael Myers, Minority StaffDirector and ChiefCounsel
Subcommittee on Public Health
BILL FRIST, Tennessee, Chairman
JUDD GREGG, New Hampshire EDWARD M. KENNEDY, Massachusetts
MICHAEL B. ENZI, Wyoming TOM HARKIN, Iowa
SUSAN M. COLLINS, Maine BARBARA A. MIKULSKI, Maryland
SAM BROWNBACK, Kansas JEFF BINGAMAN, New Mexico
JEFF SESSIONS, Alabama JACK REED, Rhode Island
JAMES M. JEFFORDS, Vermont
(Ex Officio)
Anne E. Phelps, StaffDirector
Da^/ID Nexon, Minority StaffDirector
(II)
CMS
Librarv'
I C2-07-13
7500 Security Bivd.
IIBmtDore, mrym^ 21244
CONTENTS
STATEMENTS
THURSDAY, MARCH 23, 2000
Page
Frist, Hon. Bill, a U.S. Senatorfrom the State ofTennessee 1
Fox, Claude Earl, Administrator, Health Resources and Services Administra-
tion, U.S. Department ofHealth and Human Services, Rockville, MD; and
Janet Heinrich, Associate Director, Health Financing and Public Health
Issues, U.S. GeneralAccounting Office, Washington, DC 3
Dean, Dr. Thomas M., Medical Director, Horizon Health Care, Wessington
Springs, SD, on behalf of the National Rural Health Association; Bernard
Simmons, Executive Director, Southwest Health Agency For Rural People,
Tylertown, MS, on behalfofthe National Association ofCommunity Health
Centers; Mary Bufwack, Chief Executive Officer, United Neighborhood
Health Services, Inc., Nashville, TN; Robert L. Taube, Executive Director,
Boston Health Care For the Homeless Program, Boston, MA, on behalf
ofthe National Health Care For the Homeless Council; and Larry S. Gage,
President, National Association of Public Hospitals and Health Systems,
Washington, DC 23
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.:
ClaudeEarlFox, M.D 42
JanetHeinrich 45
Thomas M. Dean, M.D 53
Bernard Simmons 55
Mary Bufwack 62
RobertL. Taube 65
Larry S. Gage 68
AmericanAcademy ofFamilyPhysicians 72
Massachusetts League ofCommunityHealthCenters 73
(III)
\
HEALTH CARE FOR THE UNINSURED: THE
ROLE OF SAFETY NET PROVTOERS
THURSDAY, MARCH 23, 2000
U.S. Senate,
Subcommittee on Public Health,
OF THE Committee on Health, Education, Labor, and
Pensions,
Washington, DC.
The subcommittee met, pursuant to notice, at 9:30 a.m., in room
SD-430, Dirksen Senate Office Building, Senator Frist (chairman
ofthe subcommittee) presiding.
Present: Senators Frist, Jeffords, Kennedy, Dodd, and Reed.
Opening Statement of Senator Frist
Senator Frist. Good morning. I apologize for running a few min-
utes late for a very important hearing this morning, one that I am
very excited about because it really does capture for me a lot ofthe
dynamics ofan area which has, I believe, in the past been less than
adequately addressed in a hearing format. I believe that today,
with our two superb panels ofwitnesses, at—the end ofthe next cou-
ple of hours, we will all be better-educated I know that I and my
colleagues will be.
Today's hearing is entitled, "Health Care for the Uninsured: The
Role ofSafety Net Providers." We are here today to discuss the Na-
tion's safety net system which is a critical factor in ensuring access
to quality health care for America's uninsured.
As many of you know, a few months ago, I joined hands with a
bipartisan and bicameral group of members and put forth a multi-
faceted approach to address the varying needs of the uninsured.
Today's hearing will focu—s on an important aspect or piece of that
comprehensive approach our safety net providers and will focus
on the critical role that they play in serving the uninsured and
medically underserved populations.
Despite America's unprecedented economic growth, we have an
uninsured population that is increasing at about 3,000 people a
day, about one million people each year. It has now increased to
44 million people, which is an increase that I believe we must ad-
dress in a systematic and comprehensive way. We must support
the life-saving role that our safety net providers play in serving our
most vulnerable populations, those populations who cannot afford
to pay out-of-pocket for their health care.
This morning as we exami—ne our safety net system, we will focus
on three primary programs the National Health Service Corps,
(1)
2
the Consolidated Health Centers Program, and the Community Ac-
cess Program. Together, these three programs service millions of
medically underserved areas, serving the uninsured and others.
Since 1972, the National Health Service Corps has placed over
20,000 health care providers in health professional shortage areas
through scholarship and loan repayment programs. Today, over 4
million receive care from 2,500 NHCS providers in the field.
However, even with over 4,000 shortage areas being served by
the National Health Service Corps, only 12 percent ofthe need has
thus far been met.
As the committee looks to reauthorize the program this year,
these are among the issues to be considered, and unmet need will
be an important one ofthese issues.
In 1996, the Health Centers Consolidation Act reauthorized the
community health centers, the migrant health centers, health cen-
ters for the homeless, health centers for residents of public hous-
ing, and the Healthy Schools Program, until 2001. Today, these
health centers serve nearly 9 million people, 41 percent of whom
are uninsured with one-third ofthose uninsured being children.
Health centers today must operate in an environment that is
very, very different from even a few years ago. The result of a
health care industry which continues to evolve at a very rapid
pace. Each year, health centers are faced with a growing number
ofuninsured. Demographic changes and increased reliance on man-
aged care and decreasing Medicaid payments have placed new fi-
nancial pressures on health centers' ability to continue to provide
care.
As we look to reauthorize this program, it will be critical to ac-
knowledge and address all of these factors to ensure that our Na-
tion's health centers can continue to meet the enormous need for
health care services.
Providing support for the development of integrated systems is
one aspect ofimproving our safety net system. The Community Ac-
cess Program, although not authorized, received appropriations of
$25 million for fiscal year 2000 in an effort to assist communities
and safety net providers to develop that important infrastructure
necessary to participate in integrated health systems and coordi-
nate care for the uninsured.
As we continue to address the needs ofour safety net system, in-
tegration and collaboration within communities to provide care will
all be important components in strengthening the system overall.
I am very pleased to have so many distinguished witnesses today
and especially want to welcome my Tennesseans who are with us,
as well as the many representatives of community health centers
who are in the audience today.
In terms of procedure for our witnesses, we will follow the tradi-
tional committee policy with regard to opening statements, allow-
ing individuals and my colleagues to place statements into the
record. We will hear brief opening remarks from our witnesses on
each of the two panels. I would like panelists if possible to keep
their remarks relatively short, approximately 5 minutes in length.
We will be using our lighting system, although we will not be using
it too strictly, because I want you to be able to make all the impor-
tant points that you would like to make.
After each panel completes their opening remarks, we will have
a period for questioning. Then, we will keep the hearing record
open for individuals who would like to submit no more than 10
doublespaced pages of written testimony until March 30, 2000, at
which time the hearing record will be closed.
We have two panels today. The first panel will examine the Na-
tional Health Service Corps, the Consolidated Health Centers Act
of 1996, and the Community Access Programs and the important
role they play as safety net providers.
Dr. Claude Earl Fox is administrator of the Health Resources
and Services Administration which leads the Nation's efforts to in-
crease access to health care for all Americans through a broad
array of grant and health promotion programs. In this role and in
his previous role as HRSA's acting administrator. Dr. Fox has been
instrumental in many departmental initiatives, such as SCHIP, the
State Children's Health Insurance Program, the Presidential Initia-
tive to Eliminate Racial Disparities in Health, and Healthy People
2010. He has also enjoyed a distinguished public health career at
the State and local levels. He received his M.D. degree from the
University ofMississippi School ofMedicine and a master of public
health degree from the University ofNorth Carolina.
Dr. Janet Heinrich is associate director of the Health Financing
and Public Health Issues Division at the U.S. General Accounting
Office. As a witness representing the GAO, Dr. Heinrich will focus
on the GAO report on community health centers, released today.
She was director of the American Academy of Nursing for 7 years
and previously served as director of extramural programs within
the National Institute of Nursing Research at the NIH. She is a
graduate of the University of Michigan School of Nursing and in
addition received a master's of public health from the Johns Hop-
kins University and a doctorate ofpublic health from Yale.
I want to formally welcome both ofour panelists at thisjuncture.
Senator Reed, would you like to make an opening statement? If
not, we will proceed with the witnesses.
Senator Reed. No, Mr. Chairman. Thank you.
Senator Frist. Thank you.
Dr. Fox, if you would begin, and again, I appreciate your being
with us today.
STATEMENTS OF CLAUDE EARL FOX, ADMINISTRATOR,
HEALTH RESOURCES AND SERVICES ADMINISTRATION, U.S.
DEPARTMENT OF HEALTH AND HUMAN SERVICES, ROCK-
VnXE, MD; AND JANET HEINRICH, ASSOCIATE DIRECTOR,
HEALTH FINANCING AND PUBLIC HEALTH ISSUES, U.S. GEN-
ERALACCOUNTING OFFICE, WASHINGTON, DC
Mr. Fox. Thank you. Senator. I am pleased to be here. You have
my written statement.
I am accompanied by Dr. Marilyn Gaston, who is associated ad-
ministrator for the Bureau of Primary Care, and many other staff
and people who have woven this safety net.
We are very pleased to be here because HRSA really is about ac-
cess to care, both trying to make sure that people can get into the
health care system as well as to reduce the racial disparities.
4
You have already alluded to the increasing number ofpeople who
are uninsured, which is a real problem. I want to run through the
three programs, and then I will look forward to your questions.
The first is the CAP program. This is a program that is yet to
be. We have the request for applications out on the street. We have
$25 million, and we anticipate funding about 20 to 30 projects, and
we already have application requests for 1,900. So we are going to
have a huge demand, and I think this is a reflection both of the
need out there as well as the interest in this area. We plan to pro-
vide a lot offlexibility around the kinds of grants we fund. We will
absolutely require some things like collaboration and sustainability
and leveraging of resources. So this is going to be an interesting
program that we look forward to getting in place.
The second program I want to talk about is the National Health
Service Corps. This program is one that in my opinion, although
it has been around for 25 years, still has a huge, huge untapped
potential to provide health professionals across the country. The
Council on Graduate Medical Education said that we may indeed
be producing too many physicians, but that they are not the right
kind in the right places, and they do not look like the communities
they are trying to serve. Those are things that we think we can
cure with the National Health Service Corps.
We have Corps physicians in each State, but I will tell you that,
as you have already alluded to, we are only funding 12 percent of
the need. We have a huge pent-up demand for Corps physicians
and other practitioners. Sixty percent of our Corps providers serve
in rural communities, and most of them stay in service, if not in
that community, in another community. So we feel like we have a
good track record. We are serving in communities where people
often will not go, some even in my home town in the rural Mis-
sissippi Delta.
So we look forward to talking more with you about the National
Health Service Corps.
Finally, the Consolidated Health Centers. We fund right now
some 700-plus centers that have over 3,000 sites. We are now serv-
ing, combined with the National Health Service Corps and with
community health centers, somewhere around 11 to 12 million peo-
ple. Again, this is against a backdrop of about 44 million people
that we know are in underserved areas. So again, there is a huge
unmet need.
We are only funding about 20 percent of application for health
centers each year, even with the $100 million that Congress has
been gracious enough to give us each year for the last couple of
years. Our health centers are generally in areas where care is not
available. We also know. Senator, that we make a difference. In my
opinion, we provide better care than many other providers. The
people who come to our centers are high-risk from an income
standpoint and for a lot of other reasons. We know that they get
mammograms more often than women in the general population.
We know that people with high blood pressure are more commonly
controlled. We know that Medicaid patients who come to health
centers versus those who do not have fewer hospitalizations.
We have a lot of data, and we feel like we can not only tell you
that we are in the right places, but that apparently, we are doing
5
the right things, and we feel like we are making a difference in
many of the health conditions that face this Nation. Also, approxi-
mately two-thirds of the people that w^e serve in health centers are
minorities.
We also fund Health Care for the Homeless, a huge and growing
problem, and migrant health centers. Again, we have an increasing
problem in migrant health care in this countr>% a problem where
people lose Medicaid eligibility when they move across States.
So again, we are really proud ofboth the National Health Service
Corps and the Community Health Centers and the other health
centers that we fund and what they do. We see them in many ways
as the linchpin of the CAP program. They are going to be a part
of that. I think the strength of the CAP program is that it is going
to involve everj'body, we hope, from the public hospitals, other
groups, inpatient, outpatient, tertiary care, primary care. What we
hope to do Vrith the CAP program is to use our Community Health
Centers, our National Health Service Corps, and our other grantees
to really weave together what we hope will be a stronger system
for every community to make sure that people who fall between
Medicaid and private insurance have access to care.
I am going to stop here, and I look forw^ard to your questions.
Senator Frist. Thank you. Dr. Fox.
[The prepared statement of Dr. Fox may be found in additional
material.]
Senator Fkist. Dr. Heinrich, welcome.
Ms. Heixrich. Thank you.
I am pleased to be here today as you discuss the Federal safety
net programs intended to improve access to medically-underserved
populations.
My statement focuses on the Community Migrant Health Center
Program and the National Health Service Corps. As you noted, my
comments on the centers program is based on our report on health
centers being released today at the request ofyou and Senator Jef-
fords.
Community Migrant Health Centers have offered primary and
preventive health services, along with enabling services such as
transportation to appointments, since they were established in the
sixties. The number of centers has remained stable in recent years,
while the number ofpersons recei\'ing care has increased.
However, centers face many pressures from changes in the
health care market, such as the increased number ofuninsured pa-
tients and competition for Medicaid patients. According to HRSA,
about 40 percent of the overall funded centers are doing well, are
maintaining sufficient staff capacity and serving a growing number
of patients. About 50 percent are experiencing some operational
problems, and 10 percent are struggling.
Centers have taken steps to respond to the market changes, and
if they have, they are more likely to succeed. Some try to compete
for patients and improve operations by forming partnerships and
networks. This does allow them to share expertise and resources,
such as information systems, and control costs.
Addressing the growth of managed care is another critical factor.
Some centers contract with managed care organizations; others
have actually become managed care organizations themselves. Suc-
4i
6
cessful centers know how to attract patients with diverse payment
sources, including private pay. They also pursue funding from pri-
vate donations, foundations, and local governments.
HRSA plays a critical role in maintaining the viability ofthe cen-
ters. The grants it provides are a major source of revenue. It also
plays a role in overseeing centers and providing technical assist-
ance. To evaluate overall performance of centers, HRSA each year
collects administrative, demographic, financial and utilization data
on each center. This information, however, has limitations for mon-
itoring and evaluating performance. For example, the financial
data cannot provide an accurate indication ofan individual center's
status because costs are reported on an accrual basis while reve-
nues are reported on a cash basis. We have recommended that
HRSA take steps to improve the quality, accuracy, and timeliness
ofthe data to facilitate its oversight and assistance to centers.
Let me now turn to the National Health Service Corps. At the
end of fiscal year 1999, the Corps had 2,526 physicians, dentists,
nurse practitioners and other providers in shortage areas. Each
year, the Corps receives many more requests from communities for
health professionals than it can meet. As a result of this challenge
to use resources efficiently, we have four suggests in that regard.
First, we suggest that Congress consider modifying the current
requirements regarding the distribution of funds between scholar-
ships and loans. Currently, scholarships receive at least 40 percent
of the funding. The loan repayment program costs less; recipients
are more likely to complete their service obligations, and they are
also more likely to continue practicing in the underserved commu-
nity.
This is not to say that the scholarship program should be elimi-
nated. In fact, it should be used more effectively to direct recipients
to the neediest communities.
Second, HRSA needs to improve the designation of shortage
areas. Over the past 5 years, we have reported on a number of
problems with the process for determining whether an area is a
health professions shortage area.
In addition to problems with timeliness and quality of the data
used, we found that the approach does not count providers already
working in shortage areas, such as nurse practitioners. As a result,
the current system tends to overstate the need for more providers.
Third, it is critical that the Corps implement an effective system
for placing providers in shortage areas so that more areas receive
placements rather than allowing some areas to receive multiple
placements while others have none.
Underserved communities are—now frequently turning to another
method ofobtaining physicians extending the J-1 visa of non-U.S.
citizens who have just completed their graduate medical education.
Visa waivers have become so numerous that they now surpass the
number of Corps physicians in shortage areas. This sizable domes-
tic placement effort is rudderless. No agency has responsibility for
oversight or ensuring that placement efforts are coordinated.
Our final suggestion, then, is for coordination of the visa and
Corps programs. First, we should clarify how the use of J-1 visas
fits into the overall Federal Government strategy for addressing
underservice. This should include determining the size of the pro-
